Change My Name or Address
Name change:
You must provide previous name, as well as name change information. A copy of any or all legal documents such as marriage license, divorce decree or legal name change certificate. Please mail, fax, or e-mail scanned documents along with your signed written request to contact information provided below.
Address change:
To change your address, please click here and complete the Address Change Form. You may mail, fax, or e-mail this form using the information provided below.
· New address (Under normal circumstances the practice location address is posted on our website for public access and the mailing address is for CSBME correspondence purposes unless there is only one address on file, therefore Please state whether the new address is your mailing/home address or your practice location address)
· Signature
Please include a phone number or e-mail address so we may contact you with any questions we may have.
Send name/address change information to:
Katonya Reynolds,
Fax: 404-656-9723
e-mail: kreynolds@dch.ga.gov
ATTENTION: DO YOU ALSO WANT A NEW WALLET ID CARD?
Please be aware that we will not automatically issue you a new wallet ID card with your address and/or name change. You may request a replacement ID card with your updated name and address by completing a request form, include a $10 check or money order made payable to "GEORGIA MEDICAL BOARD", and mail to Katonya Reynolds at the above address. Click here for the DUPLICATE ID CARD REQUEST FORM or go to the "I Want To" section on our home page.
Associated Document(s):
 |
Address Change Form.pdf |
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